News 12/3/13

CMS finalizes the 2014 Medicare Physician Fee Schedule, which includes a 24 percent payment cut if the SGR formula is not amended. CMS also proposes a policy beginning in 2015 to support care management outside of routine office interactions by establishing separate payments for managing the care of certain Medicare patients. The final rule also includes provisions regarding physician quality programs and the Physician Value-Based Payment Modifier.

In a separate announcement, CMS says it will pay providers a flat rate for Medicare visits to outpatient clinics, regardless of the severity of the patient’s condition.

EMR/PM provider CureMD acquires medical billing company AviaraMD.

Elmwood Health Center (NY) becomes the first practice to submit immunization data to the New York State Immunization System across the HEALTHeLINK HIE.

EHRs offer more than just a handy way to store patient notes, according to researchers from the Palo Alto Medical Foundation Research Institute and the University of Minnesota. Researchers conclude that patient data from EHRs provide reliable measures of the process of care and the patient-centeredness of a primary care practice. They also found that the volume of electronic messages between clinicians and  the frequency of in-person patient visits were associated with better patient health outcomes.

CMS publishes an interactive tool to help providers determine their eligibility for various ehealth programs.

Entrada, a developer of workflow products that are integrated with EHRs from athenahealth, Allscripts, Greenway, and NextGen, raises $1.12 million in new equity.

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News 11/26/13

From Ralph N: “Re: Practice manager interview. That interview sounded like a paid advertisement from athena.” While Erin was clearly enthusiastic about her billing and EMR provider, be assured that vendors never pay us for interviews, Readers Writes, or other posts. On HIStalk we have a section that is clearly labeled “Sponsor Updates” that includes items that may not be considered “hard news.” Often our sponsors ask us to consider interviews with their CEOs or clients – which we do not always agree to do – but in this case athenahealth is not a sponsor. Recently we asked multiple ambulatory EMR vendors for the names of potential interview candidates who were successfully using EHRs in their practice and appreciate athenahealth’s assistance in connecting us with Erin.

Nuance Communications announces the general availability of Dragon Medical 360 l Network Edition 2.0, which allows clinicians to document using multiple devices and provides an accuracy level of 98 percent or higher out of the box.

A Virginia gastroenterologist shares his transition from an academic practice to a small private group that he labels a “medical oasis.” He finds particular pleasure in the office’s low-tech set-up and absence of an EMR, which he calls old-school, unacceptable, and effective:

I write, by hand, notes that contain the information I need to help you feel better. When I finish our visit, I dictate a letter and often call or text your referring physician to let them know what’s going on. I bill based on the notes, but no one’s costing out the "elements of the encounter."

He is happier in his work and claims his patients are as well. Somehow the story makes me sad.

CMS publishes a tip sheet for EPs on Stage 2 HIE requirements. The document outlines the required data elements and provides guidance on data sharing objectives for summary of care documents, clinical summaries, and patient electronic access. EPs that have completed at least two years of Stage 1 MU can begin Stage 2 in 2014.

The use of secure messaging portals in EHRs may not improve outcomes or costs, according to a review published in the Annals of Internal Medicine. Researchers, who considered findings from 46 studies, conclude that “portals represent a new technology with benefits that are still unclear.”

A study of 215 primary care physicians reveals a significant decline in lab ordering rates when providers have a real-time display of cost information within their EMRs.

As Mr. H mentioned on HIStalk over the weekend, we are about to hit the traditionally slow news time in HIT.  If you are like me, your to-do list for the next few weeks includes not only work, but also plenty of holiday merriment, cooking, shopping, and decorating. Be assured that we won’t keep you away from the eggnog any longer than necessary by padding our posts with irrelevant news. 

On that note, I’m not sure if there will be enough news for a second news post this week. Just in case, best wishes for a very happy Thanksgiving!

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DOCtalk by Dr. Gregg 11/22/13

Big Data, Self-Care, and a DeLorean

Feeling bored the other day, I decided it was time for a road-time trip. Thus, I pulled out the DeLorean, threw a stale grilled cheese into the Mr. Fusion, cranked up the flux capacitor, hit 88 MPH, and headed off again to the future. (I won’t say when, because I don’t want to scare folks. Let’s just say it’s sooner than you might expect.)

After exiting the space time continuum, I decided to drive over to my doctor’s office to see what had become of healthcare. Sadly, it had been replaced by a Walmart. (I noticed an amazing number of Walmarts on the way there, by the way.) Noticing a caduceus logo now featured just below the main sign, I pulled up and walked in.

A big “Wal-Care” sign was prominently positioned just inside the entry with the caduceus logo to its right. I turned in to see an array of kiosks and cubbies occupied by people tethered to digitalia and discoursing with holographic talking heads floating eerily in space above each counter. I noticed one real, white-coated person walking around and went up to make some inquiries. Her lab coat had “Dr. Cammy” embroidered above the right breast pocket.

“Dr. Cammy,” I started. She turned and smiled. “Might I ask you a few questions?”

Her smile grew larger. “Oh, my, yes!” she exclaimed with a rather mixed expression of surprise and joy. “I get so few questions these days. How can I help …” She stopped mid-sentence. “Wait…I know you…you’re that guy, that doc with the DeLorean,” she said with both pronouncement and query.

I smiled, sheepishly. “Guilty,” I say.

“So, you’re actually here from 2013, right?” she asked.

“I am,” I acknowledge.

“I’ll bet you’re curious about all this,” she said as she swept her left hand across the room.

“You’re very insightful,” I say.

“Thanks. You know, I don’t get to use my insight much anymore. Healthcare has changed so, so dramatically. I’m more custodian than caregiver, it seems. After the ‘BD&W Meld,’ the self-care appsets sort of took over, relegating docs to more monitor than mentor roles. Well, that’s true for those docs who could continue to find work anyway. I read somewhere that the majority of displaced doctors appear to have ended up selling either Amway or Mary Kay.”

“Whoa, whoa, whoa…a little fast for me,” I interrupt. “Doctors are disappearing? Self-care apps took over? And what’s this ‘BD&W Meld’ you mentioned?”

“Oh, I’m sorry,” she apologized. “That’s right. In your day, doctors were still pretty revered, weren’t they? Well, they were sometimes. All that has really changed, let me tell you. How can I condense the events…? OK. OK. I know. Remember when everybody used to go to the doctor when they were sick?”

I nod.

“Well, now that there are so many self-care appsets and devices available– and so cheap – that people go to themselves, so to speak, instead of someone else when they’re ill. They can scan and measure and examine almost anything, right from home,” she exclaims, a little bit sadly. “It doesn’t leave a whole lot for healthcare providers to do.

“For folks who don’t have the latest and greatest tools at home, they can come here and use one of our Wal-Care kiosks. It doesn’t even cost them anything, as long as they make a minimum in-store purchase.”

“Hmmm,” I ponder, trying to look less shocked than I felt. “What if they need surgery or chemo or radiation treatment or some such?”

Dr. Cammy looked around the room to see if anyone needed her. They did not. She sighed, just a smidge, and continued, “Well, between personalized genomics, robotics, Big Data, and Sir Watson, there’s far less need for ‘real’ doctors to get involved. People don’t get nearly as much invasive care anymore, not like in your day. When they do need some form of procedure, heck, sometimes they can schedule it themselves, show up, have the procedure, hang out in auto-post-op a bit, and head home without even seeing a live person.”

“Um,” I stumble, “you mention ‘Sir Watson.’ Who is tha… wait… no… you don’t mean ‘Watson,’ the IBM computer, do you?!”

“Yeah,” she chuckles. “Can you believe it? Good old England’s Queen Latifah III, herself, knighted Watson a couple of years back. It made all the news threeds. The first non-human in history to receive knighthood.”

“Threeds?” I say quizzically.

“Oh, right. You didn’t have those yet. Threeds are ‘3-Ds.’ It’s how most content is delivered anymore. Like those holographic talking heads all these people are talking with,” she said as she pointed across the room.

I think I see the connection and ask, “So then, is that the ‘BD&W Meld’ you mentioned? Big Data and Watson? Or should I say, Sir Watson?” My smirk leaks out a bit more than I intend.

“Yep, sure is,” she admits. “When they finally figured out that they could take all that mega data folks were collecting – which was mostly just sitting on a gazillion different servers doing nothing – and feed it to Watson, things went bananas. Watson just sort of looked like the Second Coming to some, spewing out all these connections that no one had ever even dreamed existed. He literally changed the world, even more than Saint Jobs. That’s how it earned its royal dubbing, even though some folks in healthcare thought it more an Antichrist than a savior.”

My mind was reeling. Big data had finally found use, but its use put providers out of business? People could now take their healthcare into their own hands – and devices? Walmart had become the major primary care player? Watson was now a ‘sir’? Jobs a saint?

“Dr. Cammy, I feel sort of faint,” I admit, feeling the wooziness all the way to my toes.

“Oh,” she says with disappointment. “Kiosk 7,” she directs.

From the trenches…

“The future ain’t what it used to be.” – Yogi Berra

Dr. Gregg Alexander, a grunt in the trenches pediatrician at Madison Pediatrics, is Chief Medical Officer for Health Nuts Media, an HIT and marketing consultant, and sits on the board of directors of the Ohio Health Information Partnership (OHIP).

HIStalk Practice Interviews Erin Angelicola, Practice Manager, Marc Feingold, MD, LLC

Erin Angelicola is practice manager, Marc Feingold, MD, LLC, Manalapan, NJ

Give me some background on the practice, your physician, and yourself.

Dr. Feingold opened his practice in Manalapan in July of 2010. We went live with our electronic medical record in 2011 knowing that Meaningful Use was coming into place soon. We were a pretty young practice so everyone that works here is gung ho about technology. Everyone is computer savvy. We’ve got a pretty technologically- inclined office and a lot of our patients as well have embraced it as we’ve moved forward with athena and our patient portal.

You’re also using athena for billing, is that correct?

We use athena for virtually everything. We use the athenaCommunicator to communicate with our patients via phone call and for all of our reminder calls to patients to remind them they have an appointment. They do mass calls in the event that God forbid we had to close the office like in Hurricane Sandy. They also have a patient portal available with the Communicator. We use the Communicator portion to get patients their labs online, to give them access to the medical records, to check their weights, their blood pressure, and things like that throughout the year.

We use the billing portion called athenaCollector and they basically handle all of the billing issues that we have in the office. They handle all of our explanation of benefits from insurance companies and if there is an issue they won’t allow us to drop a claim. It will give us a head’s up not to drop this claim because a CPT code is wrong or ICD-9 doesn’t match the CPT code. It suggests that you should reevaluate this and gives us things you don’t really get from a regular billing company.

We also use the clinical portion of athena so all of our registration, all of our patient visits – everything – is logged into athena to track all of our quality management reporting.

Tell me about the selection process when you first began looking at systems.

We looked at about ten EMR companies. We looked at everything from free EMR companies all the way up to EMR companies who weren’t cloud-based but who put a huge server in your office and it cost hundreds of thousands of dollars. So we were all over the map as far as looking at EMRs and what attracted us to athena was we wanted to be able to access our patient records no matter where we were. Dr. Feingold is pretty young and is on the go constantly so he’s running between the hospitals, he’s running into the office, he’s back and forth constantly, and then he has an active social life so he’s out running around and dating. While he’s on his date he wants to be able to refill the patient’s medication without having to say, “Oh, I’m so sorry. I have to go home to refill my patient’s medication.”

It was nice to find the cloud-based EMR that worked with us and there weren’t at the time any EMRs that were cloud-based so athena was definitely a number one choice for us for that matter.

The fact that they were constantly evolving and showing us that they were doing their updates and they weren’t charging us for updates and things like that made it kind of a no-brainer, especially for a single practitioner. We had a low cost. We didn’t have to worry about laying out this huge sum of money right off the bat when we first opened the practice so that was kind of why we went with our EMR.

Tell me about the implementation.

The implementation from paper chart to EMR, no matter who you are, no matter who you choose, is a total nightmare. Athena gave us a “to go to person” and the go to person was available that morning, first thing in the morning from 7:00 am. They called and asked, “Are you ready? Are you ready to go live? Are you excited?” And we were like, “Oh, my God, we’re never going to get this done.”

We decided we were going to completely go live and not ease into it so we decided on January 2011 that we’d not use any paper at all whatsoever in the office ever again from that point forward. In theory sounded it really great but at about 2:30 in the morning, while we were still trying to go through and do our charting, it wasn’t as fabulous as it seemed.

But the best part was the fact that we did have our account manager there with us to answer all of our questions and at 10, 11 o’clock at night she was still available helping us through it. It’s a little impressive I have to say because we thought, oh, we’re screwed, we’re not going to be able to do this. But it turned out to be a great transition. It took us about a week to get into the swing of things and it did take us almost six months to fully scan all of our previous medical records, but we did get it done in a six-month period and everyone that we saw was electronic. We have not seen a piece of paper in the office then.

How long did it take you to get back up to full speed in terms of your practice load?

That is a good question. I think it took us probably about three months to get up to a full busy load, like 20 to 30 patients a day. I think in the beginning we were averaging about 16 patients a day and after about three months we got back up to between 20 and 30 a day.

What kind of devices does the physician and the other clinicians use to input information?

We just recently updated the office so we bought 27-inch touch screen computers for all of our rooms, along with our lab, the doctor, and all of the offices. Dr. Feingold also uses his iPhone and I use my iPhone to access athena so we can get to the patient’s chart, answer any questions, or refer to the specialist. If the specialist calls while he is grocery shopping he just takes his iPhone, pulls up the patient chart, and gives them whatever information that they need. Mostly it is just our mobile devices and then the touch screen computers in the office.

Does Dr. Feingold actually input his own chart notes?

He does. He adds all of his own chart notes. We do have, of course, in the registration process someone at the front desk putting in all the demographic things. We have the medical assistants who put in the patient’s history, so before Dr. Feingold even walks into the room, the patient’s entire history, their medication, their risk status, and things like that. All of that is inputted into our system before he even walks into the room and when he gets in there he does just his charting.

As you talk with other practices, do you think that it’s easier to implement an EHR with a solo physician office versus one with multiple physicians with varying personalities and ages?

No. And the reason I say no is because it really depends on how gung ho the office is on doing it. If you have a 10-physician practice and only five of those 10 physicians want to go EMR, you are going to have a problem, but if all 10 of them are willing to go for it and their staff is behind them you will not have a problem. It involves more scheming but of course they have more staff to do that.

Really in the scheme of things, it’s really all about what is the reason behind going to EMR. If you are doing it just for the money, like for Meaningful Use money, it’s not going to work for you. But if you are doing it because you really want to improve the function of the office and want to be able to give your patients better care, you are going to have everyone behind you. I really feel strongly about that. Athena supplies you with so much information there is absolutely no way that if you want to do this you can’t do it. I mean there is no way.

Tell me a bit about the Meaningful Use process, how you implemented any changes in workflow, how you tracked your progress, and the attestation process.

We did Meaningful Use almost two years ago so we’re actually in year three of Meaningful Use Stage 1. When we went through the process, we didn’t actually have to change much because Dr. Feingold is pretty good about his charting and the information is put into the EMR for you. We have a little quality management tab in our EMR that allows us to see what a patient is missing. In the quality management tab it warns you that this patient is a smoker, so you need to do tobacco cessation counseling, and it gives you everything that you need.

At the end of the year, all we had to do is click a button and sign. Well, we had to do risk analysis of the office as well, as far our technology is concerned. Really, it was pretty easy. It was just a click of a button. I understand from speaking to other offices and going to other meetings that it wasn’t as easy for other practices, but their EMR companies didn’t give them the tools that we have.

I understand that you’re participating in Medicare’s comprehensive primary care initiative. How has your technology helped you achieve program success with that?

We wouldn’t be able to do the program unless we had EMR. There is no question about it. The reporting requirements are insane. It is totally insane. We need to report on specific quality measures. We need to make sure that our patients are getting their mammograms, that they are getting their colonoscopies, that they’re getting their BMI scans, their weight loss is improving, that the blood pressure is under control, the cholesterol is under control. The quality measures that they give you are really quite extensive. It’s all things that doctors should be doing anyway but they really hold you accountable to it.

Without an EMR, I have no idea how any doctor could possibly be accountable for the information because you would have to go through every one of your paper charts and figure out if this one had colonoscopy, if this one had a mammogram, if this one have a bone density. There is just no way to go through all of that information without a computer. I mean I have no idea how anyone could possibly do it. I just have no idea.

With the CPCI program, there is a very long application process that we went through and once we filled out the application, we showed that we were really motivated to move forward with the program and that we were onboard. They gave us a list of requirements and being on EMR and having 24/7 accessibility by our patients was one of the requirements. Without an EMR we would never be able to do that. I have no idea how anyone could function without one participating in any of these programs.

How has the use of EHR impacted the quality of care that the practice provides?

We’ve seen quite a bit of improvement with the patients. When we first started EMR, our smoking cessation counseling was about 67 percent and we’re now up to 100 percent. We’ve increased our colonoscopies by about 17 percent, which doesn’t sound like a lot, but it’s huge enough in a practice because a lot of patients just don’t want to go and get a colonoscopy because of the hassle and the work involved. And, we’ve been able to diagnose three patients with early colon cancer and we were very fortunate that all three of them have undergone treatment and all of them are well or in remission.

We’ve been able to see all the information on the screen in front of us, so you can say, hey, this patient didn’t have a colonoscopy. You better go and get it done. Or hey, this patient didn’t have a mammogram, they really need to do this. The doctor can see that right in front of him and focus on that. It works the same with the vaccines and things like that. Just the preventative medicine that is in there helps us to really make sure that we’re catching things early so that the patients are not in end stage colon cancer by the time we’re treating them for something. It’s really made a huge difference in the care that we’re giving to our patients.

You mentioned the patient portal. Tell me what kinds of things you’ve done to encourage patients’ acceptance and use.

When a patient comes into the office for their visit, they fill out their new patient form and we give them a sheet that was actually provided to us from the EMR. We give it to the patient but now also say, “Hey, we have patient portal. This is how you access it and if you have any questions, let us know.”

There have been a few times we have had elderly patients that are in Medicare that are well over 70, 80, 90 years old and they will come in and they will sit down with me and I will spend time teaching them how to use the portal. It’s pretty easy. I mean if you can get on the Internet, you can use the portal. It’s just putting in a username and password and you’re in the system. They can access it to pay bills, they can access all of their information as far as their health is concerned, see any test labs. They can print out their EKG and take it to the cardiologist.

We explain this to them because a lot of patients don’t understand the value of the portal. They don’t want to be bothered with that. I explain that if the office is closed, you can go on to your patient portal, pull up your EKG, and take it with you at 7 a.m. or 8 a.m. to the hospital for your stress test. Or you can pull up labs if you’re up at three o’clock in the morning and you can’t figure out what else to do.

You can pull up your patient portal and see what your cholesterol was. It gives them 24/7 access to their records and then they can email us instead of sitting on hold on the phone. They don’t have to call the office anymore for their refills. They don’t have to call the office to pay their bills. They don’t have to call the office to ask a question about what their cholesterol was. All of this is available online. It gives them the opportunity to see how valuable it is when we explain it that way. Then they say, “Okay, maybe I will give this a chance.” It’s been useful.

Is the practice doing anything at this point to prepare for ICD-10?

Dr. Feingold is actually the only one who enters in the ICD-9 code besides myself so when it comes down to it, the two of us have been reading up on it. I had gone to the athena user conference over in Boston this year and took a couple of classes on the ICD-10 usage. Dr. Feingold has been taking a few classes over at the hospital as well to prepare. He’s been working with the medical records team to make sure that he’s ready to go but in the end, as long as the EMR is capable of doing it, all he has to do is type in the patient’s diagnosis and it pulls the code for us.

What kind of encouragement do you provide your peers and other practices that are perhaps fearful of implementing EHR?

There have been so many. They have been saying, “We’re just going to retire because we’re not going to be able to do this.” This is ridiculous. Dr. Feingold is a huge proponent of athena and his EHR. He has talked to a few physicians in the hospital and have gotten them on board. He says, “Hey, this is something that is going to help you out. It is going to save you money. You are going to be able to get rid of a couple of staff members if you need to or if you want to, because the EMR gives you the capability of doing so much more.”

We’ve gotten a lot of hesitation and there are a lot of people who are just upset about going electronic in general. They are not computer savvy. They don’t want to do it. Their nurse is 65 years old, 70 years old, and doesn’t want to deal with this stuff. And I say to them, well, maybe it’s time for a new nurse. That’s what it is. I mean you have to have your staff behind you and if your staff is not behind you, you are never going to be able to go live with an EMR. But if your staff is behind you and you need help, hey, call our office, we’ll be happy to help you. We tell everyone and we tell everyone in the hospital. There have actually been three physicians in our hospitals now that have gone live with the EMR that we have and every single one of them has been successful in implementing the program. I can’t imagine that anyone who isn’t really willing to do it couldn’t do it.

News 11/21/13

From TruthSeeker: “Physician dissatisfaction. KLAS had a report on ambulatory EMR usability earlier this year that seems to contradict the recent IDC Health Insights report. KLAS found 55 to 85 percent of physicians were achieving high usability with their EMRs and only eight percent said they were unable to achieve even moderate usability. IDC claims that lost productivity was the top reason that almost 60 percent of physicians were dissatisfied with their EHRs.” In looking at the KLAS report it appears the focus was more on “usability” than “productivity.” Can an EMR be easy to use but not necessarily a boon to productivity? Participants in the KLAS survey were primarily physician leaders at practices with 25 or more providers, so it’s likely the KLAS survey population included an abundance of EMR champions and power users. Given the differences in the studies I don’t think you can conclude their findings contradict one another. In terms of physician dissatisfaction, I’m sure there are plenty of  “in the trenches” providers who are dissatisfied with their existing EMR products and have legitimate concerns over lost productivity.

RelayHealth Financial announces that all its financial connectivity solutions meet the current ICD-10 standards and that ICD-10 testing is available at no cost to its customers.

Hartford HealthCare Medical Group (CT) selects MediRevv to provide A/R liquidation management services for its 250 providers.

MDS Medical, Greenway Medical’s top-producing channel partner, acquires the PrimeSUITE assets and customers of EHRsolutions, Greenway’s second largest reseller.

Ophthalmology Associates (WI) selects SRS EHR for its six providers.

eClinicalWorks will invest $50 million over the next 12 months in addition to the $25 million it had already committed to enhance and expand population health solutions and patient engagement tools under its Health & Online Wellness business unit.

If you follow HIStalk regularly you may have read about my ongoing attempts to secure new insurance coverage through the HealthCare.gov marketplace. Today I got an email from the new carrier requesting additional information and asking me to name my primary care provider. I rarely get sick and haven’t had a PCP in years, so I went to the Internet to search for a potential candidate. I ending up reading a number of patient reviews from sites like Healthgrades, Yelp, and Vitals.com and found a disturbingly high percentage of doctors with ratings below the national average. I was left wondering if, 1) my new carrier only attracts crappy doctors, or, 2) people are more prone to post reviews if they have a negative experience. I am betting on the latter (and of course hoping not to test the theory any time soon). I did finally select a physician who had very positive reviews from both an ER nurse and a pharma rep. The experience has me thinking that physicians would be well-served to send their (happy) patients to these ratings sites in the same way my hairdresser and veterinarian do.

The AMA House of Delegates calls for continued advocacy to delay or cancel the implementation of ICD-10 and to seek federal legislative and regulatory reform to require funding assistance for physician practices to offset the cost of the transition.

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